NC0044253_Operator Designation_20180628

Water Pollution Control System Operator Designation F118FIVEDINCDENRIDWR
WPCSOCC
NCAC t5A 8G.0201 JUN 2018
Permittee Owner/Officer Name:
MOORESVILLE REGIONAL OFFICE
Mailing Address: (' U , I
City: (
S� p �L/y/ ��� r° "d State: �LL'ip:1i�6 �_� _ Phone #: (M - ; w/ R - � / i�(.S�
Email address,: p� ,4Qi� Al ami /I �j
Signature: ( Date: �[' 7i
..............................................................................................................................................
Facility Name: Permit #: Nccn44asJ
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP Surface Irrigation
Physical/Chemical Land Application
Collection System
..............a.............................................................................................................................
Operator in Responsible Charge (ORC)
Print Full Name:_ Y r,_ I"1' • l L(L/1'>_VC�b l u
Certificate Type / Gnde / Number: 1 ld () 510 Work Phone #: (70h) - 9 $1- 0
Signature: A
�T ---Date: ��—t
`Y certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the riles
and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
..............................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type
Signature:
Work Phone #: Llol� a0fo 4a56_
Date:T � 1
`7 certify thafI WleAblmy desig atibn as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and mgula&A pertaining to the responsibilities offli BU ORC-= e f th m-15A-NG1C-08G,0205 mid failing to do so can result. in
Disciplinary AcRons by the Water Pollution Control System Operators Certification Commission:'
............................................................................................. ............................:....................
Mail, fax or email the WPCSOCC 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadminkne! ear.aov.
Mail orfax a copy to the Asheville
appropriate Aegional office.. 2090 US Hwy 70
Swanmanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Pavetfeville
/Ftrsville
Raleigh
225 Green St
Ave
3800 Barrett Dr
Suite 714
1
Raleigh 27609
Fayetteville 28301-504ille28115Fax:
919.571A718
Fax! 910.486.070'•4.663.60
L(lenter
Phone:[phone]
Phone: [phone]'104.6
.1699Wilmingtont_Sale
m
127 Cardinal Dr
585 Waughtown St
Wilmington 28405-2845
R'instopSalem 27107
Fax: [phone]
Fax. [phone]
Phone. [phone]
I'hone: 336.771.5000
Revised 02-2013